International Journal of Surgery 13 (2015) 60e64
Contents lists available at ScienceDirect
International Journal of Surgery journal homepage: www.journal-surgery.net
Review
Virtual reality simulators and training in laparoscopic surgery Eugenia Yiannakopoulou a, *, Nikolaos Nikiteas b, Despina Perrea c, Christos Tsigris d a
Faculty of Health and Caring Professions Technological Educational Institute of Athens, Agiou Spyridonos, 12210, Aigaleo Athens, Greece 2nd Department of Propedeutic Surgery School of Medicine NKUA, Greece c Laboratory for Experimental Surgery and Surgical Research NKUA, Greece d 1st Department of Surgery School of Medicine NKUA, Greece b
h i g h l i g h t s Virtual reality simulators provide basic surgical skill training. Skills obtained through virtual reality simulation training can be transferred on the operating room. No data exist on the effect of virtual reality simulation on performance on advanced surgical procedures.
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a b s t r a c t
Article history: Received 5 August 2014 Received in revised form 12 October 2014 Accepted 12 November 2014 Available online 18 November 2014
Virtual reality simulators provide basic skills training without supervision in a controlled environment, free of pressure of operating on patients. Skills obtained through virtual reality simulation training can be transferred on the operating room. However, relative evidence is limited with data available only for basic surgical skills and for laparoscopic cholecystectomy. No data exist on the effect of virtual reality simulation on performance on advanced surgical procedures. Evidence suggests that performance on virtual reality simulators reliably distinguishes experienced from novice surgeons Limited available data suggest that independent approach on virtual reality simulation training is not different from proctored approach. The effect of virtual reality simulators training on acquisition of basic surgical skills does not seem to be different from the effect the physical simulators. Limited data exist on the effect of virtual reality simulation training on the acquisition of visual spatial perception and stress coping skills. Undoubtedly, virtual reality simulation training provides an alternative means of improving performance in laparoscopic surgery. However, future research efforts should focus on the effect of virtual reality simulation on performance in the context of advanced surgical procedure, on standardization of training, on the possibility of synergistic effect of virtual reality simulation training combined with mental training, on personalized training. © 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
Keywords: Virtual reality simulators Laparoscopic surgery Surgical education
1. Introduction Laparoscopic techniques have created a new paradigm in laparoscopic training with a move away from the apprenticeship model towards structured programs of teaching new skills outside the operating room in the laparoscopic training institute. Traditionally residents have been trained in the classical apprenticeship format with hands on training in the operating room. Technical skill training in general surgery progresses through the phase of gradual participation to the role of first assistant. Unfortunately in
* Corresponding author. E-mail address: [email protected] (E. Yiannakopoulou). http://dx.doi.org/10.1016/j.ijsu.2014.11.014 1743-9191/© 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
laparoscopy, the first assistant may manipulate one or more fixed instruments and has little opportunity during the operation to practice the actual maneuvers involved in laparoscopic surgery, which differ significantly from those practiced in open procedures [1]. Moreover, laparoscopic surgery is technically demanding and requires specific psychomotor abilities and skills that are different from those needed in conventional surgery [2]. These skills include: altered tactile feedback, different eye-hand co-ordination, translation of two dimensional video image to a three dimensional working area, and the fulcrum effect [3,4]. All these skills are difficult to be obtained in the operating room [5]. Currently, there are several training models available, that roughly can be categorized as box trainers, hybrid simulators, virtual reality simulators, augmented reality simulators, laboratory
E. Yiannakopoulou et al. / International Journal of Surgery 13 (2015) 60e64
animals and cadaver models [Table 1]. Inanimate box trainers are often used for laparoscopic simulator training and the performance on these trainers has been found to be well correlated with intraoperative assessments of residents performing a laparoscopic procedure. However, traditional box-trainers lack objective assessment of performance [6]. Hybrid simulators, by combining real instruments and physical training models with computer mentoring offer objective software generated evaluation of task performance through instrument motion analysis while retaining the features of a simple box trainer [7]. Virtual reality laparoscopic surgical simulators are considered to represent educational tools with great potential. Virtual reality simulators can provide basic skills training without supervision in a controlled environment and free of pressure of the operation on patients. They can also offer objective performance assessment without the need for monitored human supervision and directly measure multiple aspects of a subject's psychomotor performance on specific laparoscopic skills. However, they lack realistic haptic feedback [6]. On the other hand, augmented reality combines a virtual reality setting with real physical materials, instruments and feedback [6]. A number of studies have compared different training models with the main finding being that training based on a combination of models is more effective than one model based training [7e16]. Compared to aviation, where virtual reality training has been standardized and virtual reality simulators have proved their benefits, the objectives, needs and means of virtual reality simulation in laparoscopic surgery is still a matter of investigation. Training with virtual reality simulators should be effective, i.e. objectives have to be met and efficient i.e. minimization of time and cost. Different standards have to be met according to the level of surgeon's performance at which the training is to be achieved. 2. Virtual reality simulation training Most of the published trials investigate the validity of virtual reality simulator trainers as assessment tools. Different virtual reality simulators have been investigated including MIST-VR, LaSim, Simsurgery, Lap-Mentor, Sinergia. MIST-VR enables performance of basic laparoscopic tasks, LapSim and Simsurgery enable teaching of basic laparoscopic skills i.e. camera navigation, instrument navigation, instrument co-ordination, clip application, intra-corporeal knots, vessel dissection, as well as training in laparoscopic cholecystectomy and bowel anastomosis. On the other hand, LapMentor
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besides the former basic tasks and basic laparoscopic procedures, provides simulation of laparoscopic sigmoidectomy and gastric bypass. Training areas where the effect of virtual reality simulator trainers has been investigated include basic skill learning in laparoscopic surgery, basic skill training in robotic surgery, training in laparoscopic cholecystectomy, training in minimally invasive surgical techniques i.e. percutaneous renal access. Limited data exist on the effect of virtual reality simulation training on the acquisition of non technical skills such as visual spatial perception and psychomotor skills i.e. stress coping skills [17e19]. Limited data exist on the effect of virtual reality simulator training on performance on advanced laparoscopic procedures. The effect of virtual reality simulator to improve skills has been proved at a novice level for basic laparoscopic and minimally invasive surgical skills and for advanced suturing skills. Pre-post training tests have been used for assessment of performance [7,20e29]. In addition, limited data suggest that independent approach on virtual reality simulation training is not different from proctored approach [30e33]. It seems, that skills obtained through virtual reality simulation training can be transferred on the operating room. It has been evidenced for laparoscopic cholecystectomy in the operating room although not for all parameters investigated [34e39]. It has also been evidenced for laparoscopic salpingectomy, endoscopic sinus surgery, minimally invasive techniques in urology i.e percutaneous renal access, cysteo-urethroscopic skills as well as for intracorporeal knot tying [40e45]. However, there is limited number of studies and limited number of participants. Moreover, in a number of studies, skill transferring ability has been evaluated in cadavers, ex vivo tissues in the case of robotic surgery or animal models, not in real patients [46,47]. In addition, there are studies that fail to demonstrate predictive validity of virtual reality simulation training [48]. Concerning the effect of virtual reality simulator training on clinical results, no relevant data have been published. Although limited and contradictory data exist, the effect of virtual reality simulation training on acquisition of basic surgical skills has not been reliably proven to be different from the effect of physical simulators [9e16]. Performance on virtual reality simulators distinguishes experienced from novice surgeons. However, there are not objective standards to differentiate experienced from novices and arbitrary cut off points have been used in different trials [49e57].
Table 1 Comparative analysis of various training models. Training Model
Advantages
Limitations
Effect
Box trainers
Inexpensive, provide realistic haptic feedback
Box-trainers lack objective assessment of performance
Hybrid simulators
Provide objective metrics for laparoscopic task performance Provide objective metrics for laparoscopic task performance; provide explanations of practiced tasks Provide realistic haptic feedback and objective assessment of the performance of the trainee Provide realistic operative training experience
Lack haptic feedback
basic laparoscopic skill acquisition such as hand-eye coordination, depth perception, and knot-tying Basic and advanced laparoscopic skill acquisition Basic and advanced laparoscopic skill acquisition
Virtual reality simulators
Augmented reality simulators
Laboratory animals
Cadaver models
Provide perfect anatomy, normal tissue consistency and a realistic operative training experience
Lack haptic feedback
Expensive
Expensive, anatomical differences from human body Limited number of available human cadavers
Basic and advanced laparoscopic skill acquisition; ideal for laparoscopic suturing training Advanced laparoscopic skill acquisition, such as dissection, cutting, coagulation, and stitching Advanced laparoscopic skill acquisition, such as dissection, cutting, coagulation, and stitching
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3. Role of virtual reality simulators in surgical education Virtual reality simulation training in laparoscopic surgery offers the possibility of training without the use of real patients. Simulation provides a means of risk free learning in complex, critical or rare situations as well as promoting team based and interdisciplinary approaches to learning in health care. Furthermore, simulation can play a significant role in outcome assessment and accreditation. Virtual reality means the simulation of different skills encountered in real life through computer. The trainee reacts in a scenario with elements that resemble real and that can be changed and adjusted according to the targeted level of performance. Thus, virtual reality simulators consist a promising means of training in laparoscopic surgery. However, time and cost are invested for virtual reality simulation training and therefore its effectiveness as a means of training needs to be evidenced. In the context of minimally invasive surgery that is currently an ongoing evolving field, residents, novice surgeons as well as surgeons of different levels of expertise need to learn basic skills, to be trained in basic and advanced laparoscopic procedures or to be trained in rarely encountered situations. Thus, the effectiveness of virtual reality simulation training should be evidenced for different levels of human behavior. Rasmussen's model distinguishes three levels of human behavior: skills based, rule based and knowledge based behavior [58]. Skills based behavior concerns surgeon behaviors that take place without conscious control such as moving the instruments due to the fulcrum effect. Suturing is an example of skill based behavior. Training at this level can be performed on box trainers or virtual reality simulators. Rule based behavior concerns task execution that is controlled by rules or procedures. An example of task at this level is the operation protocol defining the sequence of steps to be performed. For example, in laparoscopic surgery the cystic duct and cystic artery have to be isolated and identified before divided. Knowledge based behavior concerns unfamiliar situations for which no formal rules exist, i.e. internal bleeding and damage to the tissue [58]. Evaluation of training tools or training methods often follows the Kirkpatrik's four level model that was developed to assess training effectiveness. According to this model, evaluation begins at the lowest level and information from each prior level serves as a basis for next level's evaluation. The levels are as follows: level 1: reactions measure how trainees react to the training program: face validity; level 2: learning-assesses the extent to which trainees have made progress to performance: construct validity; level 3: behavior/transfer: measures the change in behavior due to the training program; level-4: results: assesses training in terms of clinical results i.e. reduction in the number of complications [59]. In the context of Kirkpatrik's model, available data suggest that virtual reality simulation training positively affects trainee's progress to performance in terms of skill based behavior and rule based behavior. Predictive validity of virtual reality simulators i.e. skill transferring has also been evidenced in skill base behavior and rule based behavior. Virtual reality simulation training in the context of knowledge based behavior has not been attempted yet and possible relevant technology has to be evolved. An interesting systematic review published by Gurusamy et al. [60] three years ago investigated whether virtual reality simulator training can supplement and/or replace conventional laparoscopic training in surgical trainees with limited or no previous experience. Twenty two trials involving 622 participants were identified comparing virtual reality simulator training with other means of training including video trainer training, no training, standard laparoscopic training or different methods of virtual reality training. The authors concluded that virtual reality simulation
Table 2 Summary of findings table. Question
Main finding
Suggestions for further research
What's the effect of virtual reality simulator training on basic and advanced laparoscopic skill acquisition?
At the novice level, virtual reality simulator training leads to the acquisition of basic laparoscopic skills and of advanced suturing skills.
Further research is needed on standardization of virtual reality simulation training; on the possibility of synergistic effect of virtual reality simulation in conjunction with mental training; on personalized training Further research is needed especially for advanced laparoscopic procedures
Skill transfer has been evidenced for laparoscopic cholecystectomy in the operating room although not for all parameters investigated Limited data suggest that What's the effect of virtual reality simulator virtual reality simulator training on training improves performance on advanced performance on advanced laparoscopic laparoscopic procedures such as laparoscopic procedures? colectomy Limited data suggest that What's the effect of virtual reality simulator virtual reality simulator training on training leads to the the acquisition of non acquisition of non technical skills such as technical skills visual spatial perception and psychomotor skills? There are no relevant data What's the effect of virtual reality simulator training on patient outcome? What's the effect of virtual reality simulator training on skill transfer on the operating room?
Further research is needed in conjunction with detailed analysis of the technique of advanced laparoscopic procedures Further research is needed especially in the field of stress coping skills
Further research is needed
training improves standard surgical training and is at least as effective as video trainer training [60]. Undoubtedly, virtual reality simulators present a new paradigm in surgical education [Table 2]. Further research efforts should focus on the following issues: (i) on the effect of virtual reality simulation training on performance in the context of advanced laparoscopic procedures, (ii) on the effect of virtual reality simulation training on knowledge based behavior, (iii) on the effect of virtual reality simulation training on patient outcome (iv) on standardization of virtual reality simulation training (v) on the possibility of synergistic effect of virtual reality simulation in conjunction with mental training (vi) on personalized training. Ethical approval None required. Funding None. Author contribution Yiannakopoulou Eugenia: Study conception and design, acquisition of data, analysis and interpretation of data, drafting of the manuscript, critical revision of the manuscript. Nikiteas Nikolaos:acquisition of data and critical revision of the manuscript. Perrea Despina:analysis and interpretation of data. Tsigris Christos: critical revision of the manuscript.
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Conflicts of interest None.
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Contents lists available at ScienceDirect
International Journal of Surgery journal homepage: www.journal-surgery.net
Review
Virtual reality simulators and training in laparoscopic surgery Eugenia Yiannakopoulou a, *, Nikolaos Nikiteas b, Despina Perrea c, Christos Tsigris d a
Faculty of Health and Caring Professions Technological Educational Institute of Athens, Agiou Spyridonos, 12210, Aigaleo Athens, Greece 2nd Department of Propedeutic Surgery School of Medicine NKUA, Greece c Laboratory for Experimental Surgery and Surgical Research NKUA, Greece d 1st Department of Surgery School of Medicine NKUA, Greece b
h i g h l i g h t s Virtual reality simulators provide basic surgical skill training. Skills obtained through virtual reality simulation training can be transferred on the operating room. No data exist on the effect of virtual reality simulation on performance on advanced surgical procedures.
a r t i c l e i n f o
a b s t r a c t
Article history: Received 5 August 2014 Received in revised form 12 October 2014 Accepted 12 November 2014 Available online 18 November 2014
Virtual reality simulators provide basic skills training without supervision in a controlled environment, free of pressure of operating on patients. Skills obtained through virtual reality simulation training can be transferred on the operating room. However, relative evidence is limited with data available only for basic surgical skills and for laparoscopic cholecystectomy. No data exist on the effect of virtual reality simulation on performance on advanced surgical procedures. Evidence suggests that performance on virtual reality simulators reliably distinguishes experienced from novice surgeons Limited available data suggest that independent approach on virtual reality simulation training is not different from proctored approach. The effect of virtual reality simulators training on acquisition of basic surgical skills does not seem to be different from the effect the physical simulators. Limited data exist on the effect of virtual reality simulation training on the acquisition of visual spatial perception and stress coping skills. Undoubtedly, virtual reality simulation training provides an alternative means of improving performance in laparoscopic surgery. However, future research efforts should focus on the effect of virtual reality simulation on performance in the context of advanced surgical procedure, on standardization of training, on the possibility of synergistic effect of virtual reality simulation training combined with mental training, on personalized training. © 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
Keywords: Virtual reality simulators Laparoscopic surgery Surgical education
1. Introduction Laparoscopic techniques have created a new paradigm in laparoscopic training with a move away from the apprenticeship model towards structured programs of teaching new skills outside the operating room in the laparoscopic training institute. Traditionally residents have been trained in the classical apprenticeship format with hands on training in the operating room. Technical skill training in general surgery progresses through the phase of gradual participation to the role of first assistant. Unfortunately in
* Corresponding author. E-mail address: [email protected] (E. Yiannakopoulou). http://dx.doi.org/10.1016/j.ijsu.2014.11.014 1743-9191/© 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
laparoscopy, the first assistant may manipulate one or more fixed instruments and has little opportunity during the operation to practice the actual maneuvers involved in laparoscopic surgery, which differ significantly from those practiced in open procedures [1]. Moreover, laparoscopic surgery is technically demanding and requires specific psychomotor abilities and skills that are different from those needed in conventional surgery [2]. These skills include: altered tactile feedback, different eye-hand co-ordination, translation of two dimensional video image to a three dimensional working area, and the fulcrum effect [3,4]. All these skills are difficult to be obtained in the operating room [5]. Currently, there are several training models available, that roughly can be categorized as box trainers, hybrid simulators, virtual reality simulators, augmented reality simulators, laboratory
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animals and cadaver models [Table 1]. Inanimate box trainers are often used for laparoscopic simulator training and the performance on these trainers has been found to be well correlated with intraoperative assessments of residents performing a laparoscopic procedure. However, traditional box-trainers lack objective assessment of performance [6]. Hybrid simulators, by combining real instruments and physical training models with computer mentoring offer objective software generated evaluation of task performance through instrument motion analysis while retaining the features of a simple box trainer [7]. Virtual reality laparoscopic surgical simulators are considered to represent educational tools with great potential. Virtual reality simulators can provide basic skills training without supervision in a controlled environment and free of pressure of the operation on patients. They can also offer objective performance assessment without the need for monitored human supervision and directly measure multiple aspects of a subject's psychomotor performance on specific laparoscopic skills. However, they lack realistic haptic feedback [6]. On the other hand, augmented reality combines a virtual reality setting with real physical materials, instruments and feedback [6]. A number of studies have compared different training models with the main finding being that training based on a combination of models is more effective than one model based training [7e16]. Compared to aviation, where virtual reality training has been standardized and virtual reality simulators have proved their benefits, the objectives, needs and means of virtual reality simulation in laparoscopic surgery is still a matter of investigation. Training with virtual reality simulators should be effective, i.e. objectives have to be met and efficient i.e. minimization of time and cost. Different standards have to be met according to the level of surgeon's performance at which the training is to be achieved. 2. Virtual reality simulation training Most of the published trials investigate the validity of virtual reality simulator trainers as assessment tools. Different virtual reality simulators have been investigated including MIST-VR, LaSim, Simsurgery, Lap-Mentor, Sinergia. MIST-VR enables performance of basic laparoscopic tasks, LapSim and Simsurgery enable teaching of basic laparoscopic skills i.e. camera navigation, instrument navigation, instrument co-ordination, clip application, intra-corporeal knots, vessel dissection, as well as training in laparoscopic cholecystectomy and bowel anastomosis. On the other hand, LapMentor
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besides the former basic tasks and basic laparoscopic procedures, provides simulation of laparoscopic sigmoidectomy and gastric bypass. Training areas where the effect of virtual reality simulator trainers has been investigated include basic skill learning in laparoscopic surgery, basic skill training in robotic surgery, training in laparoscopic cholecystectomy, training in minimally invasive surgical techniques i.e. percutaneous renal access. Limited data exist on the effect of virtual reality simulation training on the acquisition of non technical skills such as visual spatial perception and psychomotor skills i.e. stress coping skills [17e19]. Limited data exist on the effect of virtual reality simulator training on performance on advanced laparoscopic procedures. The effect of virtual reality simulator to improve skills has been proved at a novice level for basic laparoscopic and minimally invasive surgical skills and for advanced suturing skills. Pre-post training tests have been used for assessment of performance [7,20e29]. In addition, limited data suggest that independent approach on virtual reality simulation training is not different from proctored approach [30e33]. It seems, that skills obtained through virtual reality simulation training can be transferred on the operating room. It has been evidenced for laparoscopic cholecystectomy in the operating room although not for all parameters investigated [34e39]. It has also been evidenced for laparoscopic salpingectomy, endoscopic sinus surgery, minimally invasive techniques in urology i.e percutaneous renal access, cysteo-urethroscopic skills as well as for intracorporeal knot tying [40e45]. However, there is limited number of studies and limited number of participants. Moreover, in a number of studies, skill transferring ability has been evaluated in cadavers, ex vivo tissues in the case of robotic surgery or animal models, not in real patients [46,47]. In addition, there are studies that fail to demonstrate predictive validity of virtual reality simulation training [48]. Concerning the effect of virtual reality simulator training on clinical results, no relevant data have been published. Although limited and contradictory data exist, the effect of virtual reality simulation training on acquisition of basic surgical skills has not been reliably proven to be different from the effect of physical simulators [9e16]. Performance on virtual reality simulators distinguishes experienced from novice surgeons. However, there are not objective standards to differentiate experienced from novices and arbitrary cut off points have been used in different trials [49e57].
Table 1 Comparative analysis of various training models. Training Model
Advantages
Limitations
Effect
Box trainers
Inexpensive, provide realistic haptic feedback
Box-trainers lack objective assessment of performance
Hybrid simulators
Provide objective metrics for laparoscopic task performance Provide objective metrics for laparoscopic task performance; provide explanations of practiced tasks Provide realistic haptic feedback and objective assessment of the performance of the trainee Provide realistic operative training experience
Lack haptic feedback
basic laparoscopic skill acquisition such as hand-eye coordination, depth perception, and knot-tying Basic and advanced laparoscopic skill acquisition Basic and advanced laparoscopic skill acquisition
Virtual reality simulators
Augmented reality simulators
Laboratory animals
Cadaver models
Provide perfect anatomy, normal tissue consistency and a realistic operative training experience
Lack haptic feedback
Expensive
Expensive, anatomical differences from human body Limited number of available human cadavers
Basic and advanced laparoscopic skill acquisition; ideal for laparoscopic suturing training Advanced laparoscopic skill acquisition, such as dissection, cutting, coagulation, and stitching Advanced laparoscopic skill acquisition, such as dissection, cutting, coagulation, and stitching
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3. Role of virtual reality simulators in surgical education Virtual reality simulation training in laparoscopic surgery offers the possibility of training without the use of real patients. Simulation provides a means of risk free learning in complex, critical or rare situations as well as promoting team based and interdisciplinary approaches to learning in health care. Furthermore, simulation can play a significant role in outcome assessment and accreditation. Virtual reality means the simulation of different skills encountered in real life through computer. The trainee reacts in a scenario with elements that resemble real and that can be changed and adjusted according to the targeted level of performance. Thus, virtual reality simulators consist a promising means of training in laparoscopic surgery. However, time and cost are invested for virtual reality simulation training and therefore its effectiveness as a means of training needs to be evidenced. In the context of minimally invasive surgery that is currently an ongoing evolving field, residents, novice surgeons as well as surgeons of different levels of expertise need to learn basic skills, to be trained in basic and advanced laparoscopic procedures or to be trained in rarely encountered situations. Thus, the effectiveness of virtual reality simulation training should be evidenced for different levels of human behavior. Rasmussen's model distinguishes three levels of human behavior: skills based, rule based and knowledge based behavior [58]. Skills based behavior concerns surgeon behaviors that take place without conscious control such as moving the instruments due to the fulcrum effect. Suturing is an example of skill based behavior. Training at this level can be performed on box trainers or virtual reality simulators. Rule based behavior concerns task execution that is controlled by rules or procedures. An example of task at this level is the operation protocol defining the sequence of steps to be performed. For example, in laparoscopic surgery the cystic duct and cystic artery have to be isolated and identified before divided. Knowledge based behavior concerns unfamiliar situations for which no formal rules exist, i.e. internal bleeding and damage to the tissue [58]. Evaluation of training tools or training methods often follows the Kirkpatrik's four level model that was developed to assess training effectiveness. According to this model, evaluation begins at the lowest level and information from each prior level serves as a basis for next level's evaluation. The levels are as follows: level 1: reactions measure how trainees react to the training program: face validity; level 2: learning-assesses the extent to which trainees have made progress to performance: construct validity; level 3: behavior/transfer: measures the change in behavior due to the training program; level-4: results: assesses training in terms of clinical results i.e. reduction in the number of complications [59]. In the context of Kirkpatrik's model, available data suggest that virtual reality simulation training positively affects trainee's progress to performance in terms of skill based behavior and rule based behavior. Predictive validity of virtual reality simulators i.e. skill transferring has also been evidenced in skill base behavior and rule based behavior. Virtual reality simulation training in the context of knowledge based behavior has not been attempted yet and possible relevant technology has to be evolved. An interesting systematic review published by Gurusamy et al. [60] three years ago investigated whether virtual reality simulator training can supplement and/or replace conventional laparoscopic training in surgical trainees with limited or no previous experience. Twenty two trials involving 622 participants were identified comparing virtual reality simulator training with other means of training including video trainer training, no training, standard laparoscopic training or different methods of virtual reality training. The authors concluded that virtual reality simulation
Table 2 Summary of findings table. Question
Main finding
Suggestions for further research
What's the effect of virtual reality simulator training on basic and advanced laparoscopic skill acquisition?
At the novice level, virtual reality simulator training leads to the acquisition of basic laparoscopic skills and of advanced suturing skills.
Further research is needed on standardization of virtual reality simulation training; on the possibility of synergistic effect of virtual reality simulation in conjunction with mental training; on personalized training Further research is needed especially for advanced laparoscopic procedures
Skill transfer has been evidenced for laparoscopic cholecystectomy in the operating room although not for all parameters investigated Limited data suggest that What's the effect of virtual reality simulator virtual reality simulator training on training improves performance on advanced performance on advanced laparoscopic laparoscopic procedures such as laparoscopic procedures? colectomy Limited data suggest that What's the effect of virtual reality simulator virtual reality simulator training on training leads to the the acquisition of non acquisition of non technical skills such as technical skills visual spatial perception and psychomotor skills? There are no relevant data What's the effect of virtual reality simulator training on patient outcome? What's the effect of virtual reality simulator training on skill transfer on the operating room?
Further research is needed in conjunction with detailed analysis of the technique of advanced laparoscopic procedures Further research is needed especially in the field of stress coping skills
Further research is needed
training improves standard surgical training and is at least as effective as video trainer training [60]. Undoubtedly, virtual reality simulators present a new paradigm in surgical education [Table 2]. Further research efforts should focus on the following issues: (i) on the effect of virtual reality simulation training on performance in the context of advanced laparoscopic procedures, (ii) on the effect of virtual reality simulation training on knowledge based behavior, (iii) on the effect of virtual reality simulation training on patient outcome (iv) on standardization of virtual reality simulation training (v) on the possibility of synergistic effect of virtual reality simulation in conjunction with mental training (vi) on personalized training. Ethical approval None required. Funding None. Author contribution Yiannakopoulou Eugenia: Study conception and design, acquisition of data, analysis and interpretation of data, drafting of the manuscript, critical revision of the manuscript. Nikiteas Nikolaos:acquisition of data and critical revision of the manuscript. Perrea Despina:analysis and interpretation of data. Tsigris Christos: critical revision of the manuscript.
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Conflicts of interest None.
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